Provider Demographics
NPI:1023772480
Name:SMITH, LADYBIRD MARY
Entity type:Individual
Prefix:
First Name:LADYBIRD
Middle Name:MARY
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:128 4TH ST
Mailing Address - Street 2:APT 1
Mailing Address - City:LEOMINSTER
Mailing Address - State:MA
Mailing Address - Zip Code:01453-6064
Mailing Address - Country:US
Mailing Address - Phone:978-602-5191
Mailing Address - Fax:
Practice Address - Street 1:128 4TH ST
Practice Address - Street 2:APT 1
Practice Address - City:LEOMINSTER
Practice Address - State:MA
Practice Address - Zip Code:01453-6064
Practice Address - Country:US
Practice Address - Phone:978-602-5191
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-22
Last Update Date:2021-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAS81307853376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA100004320311Medicaid